Difference between revisions of "Kidney tumours"

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[[Image:Renal oncocytoma.jpg|thumb|250px|A kidney tumour ([[renal oncocytoma]]).]]
[[Image:Renal oncocytoma.jpg|thumb|250px|A kidney tumour ([[renal oncocytoma]]). (WC/Emmanuelm)]]
'''[[Kidney]] tumours''' - includes '''malignant kidney tumours''' and '''benign kidney tumours'''.  Medical renal diseases are dealt with in the [[medical renal diseases]] article.
'''[[Kidney]] tumours''' - includes '''malignant kidney tumours''' ('''kidney cancer''') and '''benign kidney tumours'''.  Medical renal diseases are dealt with in the [[medical renal diseases]] article.


Pediatric kidney tumours are dealt with in the ''[[pediatric kidney tumours]]'' article.
Pediatric kidney tumours are dealt with in the ''[[pediatric kidney tumours]]'' article.
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*[[Partial nephrectomy]].
*[[Partial nephrectomy]].
*[[Nephrectomy]].
*[[Nephrectomy]].
*Nephroureterectomy (includes ureter) - done for [[urothelial cell carcinoma]] (UCC) of the renal pelvis and ureteric UCC.
*[[Nephroureterectomy]] (includes [[ureter]]) - done for [[urothelial cell carcinoma]] (UCC) of the renal pelvis and ureteric UCC.
*[[Radical nephrectomy]] - includes Gerota's fascia.
*[[Radical nephrectomy]] - includes Gerota's fascia.
**May include the [[adrenal gland]].<ref name=Ref_WMSP|288>{{Ref WMSP|288}}</ref>
**May include the [[adrenal gland]].<ref name=Ref_WMSP|288>{{Ref WMSP|288}}</ref>
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==Anatomy==
==Anatomy==
The anatomy is important for properly staging renal neoplasms.
Layers (superficial to deep):
Layers (superficial to deep):
#Renal fascia (Gerota's fascia).
#Renal fascia (Gerota's fascia).
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===Sign out===
===Sign out===
====Missed renal biopsy====
====Missed renal biopsy====
<pre>
{{Main|Missed renal biopsy}}
KIDNEY (LESION), LEFT, CORE BIOPSY:
- RENAL PARENCHYMA.
- NEGATIVE FOR MASS LESION, SEE COMMENT.
 
COMMENT:
No mass lesion is apparent in the tissue sampled. A re-biopsy should be considered.
 
Renal parenchyma:
- Glomeruli: seven glomeruli sampled, no apparent glomerular pathology on the H&E sections.
- Interstitium: interstitial fibrosis is not identified.
- Tubules: no pathology is apparent.
- Vessels: mild atherosclerosis, no hyalinization of arterioles apparent.
</pre>


=Tabular comparison (selected tumours)=  
=Tabular comparison (selected tumours)=  
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|-
|-
|IHC
|IHC
| CK7-, EMA+
| [[CK7]]-, EMA+
| AMACR+, EMA+, CK7+
| AMACR+, EMA+, CK7+
| AMACR+, E-cadherin+, CK7-
| AMACR+, E-cadherin+, CK7-
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===Tabular comparison of oncocytoma and chromophobe RCC===
===Tabular comparison of oncocytoma and chromophobe RCC===
Histomorphologic features useful to distinguish chromophobe RCC (eosinophilic variant) and oncocytoma:<ref name=pmid9844591>{{Cite journal  | last1 = Tickoo | first1 = SK. | last2 = Amin | first2 = MB. | title = Discriminant nuclear features of renal oncocytoma and chromophobe renal cell carcinoma. Analysis of their potential utility in the differential diagnosis. | journal = Am J Clin Pathol | volume = 110 | issue = 6 | pages = 782-7 | month = Dec | year = 1998 | doi =  | PMID = 9844591 }}
Histomorphologic features useful to distinguish chromophobe RCC (eosinophilic variant) and oncocytoma:<ref name=pmid9844591>{{Cite journal  | last1 = Tickoo | first1 = SK. | last2 = Amin | first2 = MB. | title = Discriminant nuclear features of renal oncocytoma and chromophobe renal cell carcinoma. Analysis of their potential utility in the differential diagnosis. | journal = Am J Clin Pathol | volume = 110 | issue = 6 | pages = 782-7 | month = Dec | year = 1998 | doi =  | PMID = 9844591 }}</ref>
</ref>
{| class="wikitable sortable"
{| class="wikitable sortable"
! Morphologic feature
! Morphologic feature
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===Common DDx===
===Common DDx===
Spindle cell tumours:
====Spindle cell tumours====
*Malignant:
Malignant spindle cell tumours of the kidney:
**[[Renal cell carcinoma with sarcomatoid differentiation]].
*[[Renal cell carcinoma with sarcomatoid differentiation]].
**[[Renal mucinous tubular and spindle cell carcinoma]].
*[[Renal mucinous tubular and spindle cell carcinoma]].
**[[Wilms tumour]].
*[[Wilms tumour]].
*Benign:
*[[Renal cell carcinoma, unclassified]].
**[[Angiomyolipoma]].
 
**[[Cystic nephroma]].
Benign spindle cell tumours of the kidney:
*[[Angiomyolipoma]].
*[[Cystic nephroma]].
 
====Renal tumours with eosinophilic cytoplasm====
{{Main|Renal tumours with eosinophilic cytoplasm}}


=WHO classification of renal neoplasia=
=WHO classification of renal neoplasia=
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*[[Papillary renal cell carcinoma]].
*[[Papillary renal cell carcinoma]].
*[[Renal papillary adenoma|Papillary adenoma]].
*[[Renal papillary adenoma|Papillary adenoma]].
*[[Chromophobe renal cell carinoma]].
*[[Chromophobe renal cell carcinoma]].
*[[Renal oncocytoma|Oncocytoma]].
*[[Renal oncocytoma|Oncocytoma]].


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*[[Clear cell sarcoma of the kidney]].
*[[Clear cell sarcoma of the kidney]].
*[[Rhabdoid tumour]].
*[[Rhabdoid tumour]].
*[[Mesoblastic nephroma|Congenital mesoblastic nephroma]]
*[[Mesoblastic nephroma|Congenital mesoblastic nephroma]].


Adults:  
Adults:  
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==Vancouver modification of WHO classification==
==Vancouver modification of WHO classification==
In 2012, several additions were made:<ref name=pmid24025519>{{Cite journal  | last1 = Srigley | first1 = JR. | last2 = Delahunt | first2 = B. | last3 = Eble | first3 = JN. | last4 = Egevad | first4 = L. | last5 = Epstein | first5 = JI. | last6 = Grignon | first6 = D. | last7 = Hes | first7 = O. | last8 = Moch | first8 = H. | last9 = Montironi | first9 = R. | title = The International Society of Urological Pathology (ISUP) Vancouver Classification of Renal Neoplasia. | journal = Am J Surg Pathol | volume = 37 | issue = 10 | pages = 1469-89 | month = Oct | year = 2013 | doi = 10.1097/PAS.0b013e318299f2d1 | PMID = 24025519 }}</ref>
In 2012/2013, several additions were made:<ref name=pmid24025519>{{Cite journal  | last1 = Srigley | first1 = JR. | last2 = Delahunt | first2 = B. | last3 = Eble | first3 = JN. | last4 = Egevad | first4 = L. | last5 = Epstein | first5 = JI. | last6 = Grignon | first6 = D. | last7 = Hes | first7 = O. | last8 = Moch | first8 = H. | last9 = Montironi | first9 = R. | title = The International Society of Urological Pathology (ISUP) Vancouver Classification of Renal Neoplasia. | journal = Am J Surg Pathol | volume = 37 | issue = 10 | pages = 1469-89 | month = Oct | year = 2013 | doi = 10.1097/PAS.0b013e318299f2d1 | PMID = 24025519 }}</ref>
*[[Tubulocystic renal cell carcinoma]].
*[[Tubulocystic renal cell carcinoma]].
*[[Acquired cystic disease associated renal cell carcinoma]].
*[[Acquired cystic disease associated renal cell carcinoma]].
*[[Clear cell papillary renal cell carcinoma]] (clear cell tubulopapillary renal cell carcinoma).
*[[Hereditary leiomyomatosis renal cell carcinoma syndrome associated renal cell carcinoma]].
*[[Hereditary leiomyomatosis renal cell carcinoma syndrome associated renal cell carcinoma]].
*MiT family translocation renal cell carcinoma - includes:
*MiT family translocation renal cell carcinoma - includes:
**[[t(6;11) renal cell carcinoma]].
**[[t(6;11) renal cell carcinoma]].


"Emerging" entities are:
"Emerging" entities (as per Vancouver) are:
*[[Thyroid-like follicular renal cell carcinoma]].
*[[Thyroid-like follicular renal cell carcinoma]].
*[[Succinate dehydrogenase-deficient renal cell carcinoma]].
*[[Succinate dehydrogenase-deficient renal cell carcinoma]].
*[[ALK translocation renal cell carcinoma]].
*[[ALK translocation renal cell carcinoma]].
==An entity proposed after Vancouver==
*[[Eosinophilic, solid and cystic renal cell carcinoma]].
*[[Biphasic hyalinizing psammomatous renal cell carcinoma]].
*[[Papillary renal neoplasm with reverse polarity]].
*[[Low-grade oncocytic renal tumour]].


=Renal cell carcinoma=
=Renal cell carcinoma=
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*Male>female (~2:1).
*Male>female (~2:1).
*Hereditary - familial syndromes (see [[Hereditary RCC]]).
*Hereditary - familial syndromes (see [[Hereditary RCC]]).
*[[Obesity]].<ref name=pmid8770461>{{Cite journal  | last1 = Chow | first1 = WH. | last2 = McLaughlin | first2 = JK. | last3 = Mandel | first3 = JS. | last4 = Wacholder | first4 = S. | last5 = Niwa | first5 = S. | last6 = Fraumeni | first6 = JF. | title = Obesity and risk of renal cell cancer. | journal = Cancer Epidemiol Biomarkers Prev | volume = 5 | issue = 1 | pages = 17-21 | month = Jan | year = 1996 | doi =  | PMID = 8770461 }}</ref>


===Subtypes of RCC===
===Subtypes of RCC===
RCC (renal cell carcinoma) comes in different subtypes:<ref name=Ref_PBoD1016>{{Ref PBoD|1016}}</ref>
RCC (renal cell carcinoma) comes in different subtypes:<ref name=Ref_PBoD1016>{{Ref PBoD|1016}}</ref>
*Clear cell carcinoma (70-80% of RCC) -- abbrev. CCRCC,
*Clear cell carcinoma (70-80% of RCC) -- abbrev. CCRCC.
*Papillary renal cell carcinoma (10-15% of RCC) -- abbrev. PRCC,
*Papillary renal cell carcinoma (10-15% of RCC) -- abbrev. PRCC.
*Chromophobe renal carcinoma (5% of RCC) -- abbrev. ChRCC,
*Chromophobe renal carcinoma (5% of RCC) -- abbrev. ChRCC.
*Collecting duct (Bellini duct) carcinoma (1% of RCC).
*Collecting duct (Bellini duct) carcinoma (1% of RCC).


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*Pathologically, this is not very difficult.   
*Pathologically, this is not very difficult.   
*On gross specimens, it is almost always obvious what one is dealing with:
*On gross specimens, it is almost always obvious what one is dealing with:
**[[UCC]] = ''nephroureterectomy''.
**[[UCC]] = ''[[nephroureterectomy]]''.
**[[RCC]] = ''partial nephrectomy'', ''nephrectomy'' or ''radical nephrectomy''.
**[[RCC]] = ''[[partial nephrectomy]]'', ''nephrectomy'' or ''[[radical nephrectomy]]''.


===Renal cell carcinoma with sarcomatoid differentiation===
===Renal cell carcinoma with sarcomatoid differentiation===
*[[AKA]] ''sarcomatoid renal cell carcinoma''.
*[[AKA]] ''sarcomatoid renal cell carcinoma''.
====General====
{{Main|Renal cell carcinoma with sarcomatoid differentiation}}
Features:<ref name=pmid11224597>{{Cite journal  | last1 = de Peralta-Venturina | first1 = M. | last2 = Moch | first2 = H. | last3 = Amin | first3 = M. | last4 = Tamboli | first4 = P. | last5 = Hailemariam | first5 = S. | last6 = Mihatsch | first6 = M. | last7 = Javidan | first7 = J. | last8 = Stricker | first8 = H. | last9 = Ro | first9 = JY. | title = Sarcomatoid differentiation in renal cell carcinoma: a study of 101 cases. | journal = Am J Surg Pathol | volume = 25 | issue = 3 | pages = 275-84 | month = Mar | year = 2001 | doi =  | PMID = 11224597 }}</ref>
*Not recognized as a distinct entity in 2004 WHO classification.<ref name=pmid16442207>{{Cite journal  | last1 = Lopez-Beltran | first1 = A. | last2 = Scarpelli | first2 = M. | last3 = Montironi | first3 = R. | last4 = Kirkali | first4 = Z. | title = 2004 WHO classification of the renal tumors of the adults. | journal = Eur Urol | volume = 49 | issue = 5 | pages = 798-805 | month = May | year = 2006 | doi = 10.1016/j.eururo.2005.11.035 | PMID = 16442207 }}</ref>
**It is considered an indicator of progression.
**Previously considered a distinct entity.<ref name=pmid16442207/><ref name=pmid10080595>{{Cite journal  | last1 = Cangiano | first1 = T. | last2 = Liao | first2 = J. | last3 = Naitoh | first3 = J. | last4 = Dorey | first4 = F. | last5 = Figlin | first5 = R. | last6 = Belldegrun | first6 = A. | title = Sarcomatoid renal cell carcinoma: biologic behavior, prognosis, and response to combined surgical resection and immunotherapy. | journal = J Clin Oncol | volume = 17 | issue = 2 | pages = 523-8 | month = Feb | year = 1999 | doi =  | PMID = 10080595 | URL = http://jco.ascopubs.org/content/17/2/523.full }}</ref>
*Tend to present at higher stage.
*Worse prognosis when adjusted for stage.
*[[Fuhrman grade]] 4 by definition.
 
====Microscopic====
Features:<ref name=pmid11224597/>
#Renal cell carcinoma.
#Sarcomatoid component:
#*[[Fibrosarcoma]] - most common.
#*[[Pleomorphic undifferentiated sarcoma|Undifferentiated]] - common.
#*[[Rhabdomyosarcoma]] - very rare.
 
Notes:
*In essence, any kidney tumour with [[spindle cell]]s should make one think of this.<ref name=pmid15763002/>
*[[Renal cell carcinoma with rhabdoid morphology|Rhabdoid change in renal cell carcinoma]] is probably analogous to sarcomatoid change.<ref name=pmid21665507>{{Cite journal  | last1 = Chapman-Fredricks | first1 = JR. | last2 = Herrera | first2 = L. | last3 = Bracho | first3 = J. | last4 = Gomez-Fernandez | first4 = C. | last5 = Leveillee | first5 = R. | last6 = Rey | first6 = L. | last7 = Jorda | first7 = M. | title = Adult renal cell carcinoma with rhabdoid morphology represents a neoplastic dedifferentiation analogous to sarcomatoid carcinoma. | journal = Ann Diagn Pathol | volume = 15 | issue = 5 | pages = 333-7 | month = Oct | year = 2011 | doi = 10.1016/j.anndiagpath.2011.03.002 | PMID = 21665507 }}</ref>
 
Images:
*[http://webpathology.com/image.asp?n=2&Case=70 Sarcomatoid change in RCC (webpathology.com)].
*[http://jco.ascopubs.org/content/27/2/235/F1.expansion Sarcomatoid changes in CCRCC (ascopubs.org)].<ref name=pmid19064974>{{Cite journal  | last1 = Golshayan | first1 = AR. | last2 = George | first2 = S. | last3 = Heng | first3 = DY. | last4 = Elson | first4 = P. | last5 = Wood | first5 = LS. | last6 = Mekhail | first6 = TM. | last7 = Garcia | first7 = JA. | last8 = Aydin | first8 = H. | last9 = Zhou | first9 = M. | title = Metastatic sarcomatoid renal cell carcinoma treated with vascular endothelial growth factor-targeted therapy. | journal = J Clin Oncol | volume = 27 | issue = 2 | pages = 235-41 | month = Jan | year = 2009 | doi = 10.1200/JCO.2008.18.0000 | PMID = 19064974 }}</ref>
*[http://www.scielo.br/img/revistas/ibju/v31n1/1a03f1.jpg Sarcomatoid changes in RCC (scielo.br)].<ref name=pmid15763002>{{Cite journal  | last1 = Dall'Oglio | first1 = MF. | last2 = Lieberknecht | first2 = M. | last3 = Gouveia | first3 = V. | last4 = Sant'Anna | first4 = AC. | last5 = Leite | first5 = KR. | last6 = Srougi | first6 = M. | title = Sarcomatoid differentiation in renal cell carcinoma: prognostic implications. | journal = Int Braz J Urol | volume = 31 | issue = 1 | pages = 10-6 | month =  | year =  | doi =  | PMID = 15763002 }}</ref>


===Renal cell carcinoma with rhabdoid morphology===
===Renal cell carcinoma with rhabdoid morphology===
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==Renal cell carcinoma grading==
==Renal cell carcinoma grading==
===General===
{{Main|Renal cell carcinoma grading}}
There are two systems:
*''Fuhrman grading'':
**Older and more complicated.
**Based on nuclear size and shape, chromatin pattern and [[nucleoli|nucleolar size]].<ref name=Ref_GUP282>{{Ref GUP|282}}</ref>
**More complicated.
*''[[ISUP]] grading'':<ref name=pmid24025520>{{cite journal |author=Delahunt B, Cheville JC, Martignoni G, ''et al.'' |title=The International Society of Urological Pathology (ISUP) grading system for renal cell carcinoma and other prognostic parameters |journal=Am. J. Surg. Pathol. |volume=37 |issue=10 |pages=1490–504 |year=2013 |month=October |pmid=24025520 |doi=10.1097/PAS.0b013e318299f0fb |url=}}</ref>
**Newer and less complicated.
**Mostly based on [[nucleoli|nucleolar size]] and to a much lesser degree on size and morphology
**Developed based on ''Fuhrman grading''.


===ISUP grading===
==Renal cell carcinoma staging==
Criteria:<ref name=pmid24025520/>
{{Main|Kidney cancer staging}}
*Grade 1 - nucleoli absent/very small at 400x. §
*Grade 2 - nucleoli seen with 400x, but not at 100x. §§
*Grade 3 - nucleoli seen at 100x, i.e. with the 10x objective.
*Grade 4 - extreme nuclear pleomorphism (esp. nuclear enlargement) ''or'' [[renal cell carcinoma with sarcomatoid differentiation|sarcomatoid differentiation]] ([[spindle cell]]s<ref name=pmid15763002/> or [[Renal cell carcinoma with rhabdoid morphology|rhabdoid cells]]).


Cavets:<ref name=pmid24025520/>
===Renal sinus invasion===
*Higher grade component trumps lower grade component.
{{Main|Kidney cancer staging}}
**No agreed upon minimum quantity of high grade component for upgrading.
***37% use 1 field of view with the x10 objective. †
***41% use 1 field of view with the x40 objective. ‡
*Grading system ''not'' used for ''[[chromophobe RCC]]''.
**The experience with the ''Fuhrman grading'' system showed it is ''not'' prognostic for chromophobe RCC.<ref name=pmid17527087>{{Cite journal  | last1 = Delahunt | first1 = B. | last2 = Sika-Paotonu | first2 = D. | last3 = Bethwaite | first3 = PB. | last4 = McCredie | first4 = MR. | last5 = Martignoni | first5 = G. | last6 = Eble | first6 = JN. | last7 = Jordan | first7 = TW. | title = Fuhrman grading is not appropriate for chromophobe renal cell carcinoma. | journal = Am J Surg Pathol | volume = 31 | issue = 6 | pages = 957-60 | month = Jun | year = 2007 | doi = 10.1097/01.pas.0000249446.28713.53 | PMID = 17527087 }}</ref>
 
Notes:
*† Suffers from [[IPFitis]].
*‡ Suffers from [[HPFitis]].
*§ Some describe Grade 1 nuclei as ''lymphocyte-like''.{{fact}}
*§§ Some suggest the following relationship between grading/nucleoli:{{fact}}
**Grade 1 = nucleoli seen at 400x.
**Grade 2 = nucleoli seen at 200x.
**Grade 3 = nucleoli seen at 100x.


==Clear cell renal cell carcinoma==
==Clear cell renal cell carcinoma==
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==Multilocular cystic renal cell carcinoma==
==Multilocular cystic renal cell carcinoma==
===General===
{{Main|Multilocular cystic renal cell carcinoma}}
*No recurrences or metastasis in the literature.<ref name=Ref_WMSP292>{{Ref WMSP|292}}</ref>
**This makes one wonder... is it really cancer.
*Case report rare.<ref name=pmid21366448>{{Cite journal  | last1 = Agarwal | first1 = S. | last2 = Agrawal | first2 = U. | last3 = Mohanty | first3 = NK. | last4 = Saxena | first4 = S. | title = Multilocular cystic renal cell carcinoma: a case report of a rare entity. | journal = Arch Pathol Lab Med | volume = 135 | issue = 3 | pages = 290-2 | month = Mar | year = 2011 | doi = 10.1043/2010-0243-LE.1 | PMID = 21366448 }}</ref>
 
===Gross===
Features:<ref name=Ref_WMSP292>{{Ref WMSP|292}}</ref>
*Cystic with thin septa.
*Well circumscribed.
 
Note:
*This tumour, radiologically, can often be separated from other cystic tumours.<ref name=pmid21722289>{{Cite journal  | last1 = You | first1 = D. | last2 = Shim | first2 = M. | last3 = Jeong | first3 = IG. | last4 = Song | first4 = C. | last5 = Kim | first5 = JK. | last6 = Ro | first6 = JY. | last7 = Hong | first7 = JH. | last8 = Ahn | first8 = H. | last9 = Kim | first9 = CS. | title = Multilocular cystic renal cell carcinoma: clinicopathological features and preoperative prediction using multiphase computed tomography. | journal = BJU Int | volume =  | issue =  | pages =  | month = Jul | year = 2011 | doi = 10.1111/j.1464-410X.2011.10247.x | PMID = 21722289 }}</ref>
===Microscopic===
Features:<ref name=Ref_WMSP292>{{Ref WMSP|292}}</ref>
*Polygonal cells within the septa.
*Clear cytoplasm.
*+/-Calcification (common).
 
DDx:
*[[Cystic renal disease]] with macrophages in the septa.
*Cystic [[clear cell renal cell carcinoma]].
*[[Tubulocystic carcinoma]].
 
===IHC===
*EMA +ve.
*Keratins +ve.
*CD68 -ve.


==Papillary renal cell carcinoma==
==Papillary renal cell carcinoma==
Michael
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